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Selected Cigarette Smoking Initiation and Quitting Behaviors Among High School Students—United States, 1997

Selected Cigarette Smoking Initiation and Quitting Behaviors Among High School Students—United States, 1997

October 01, 1998

The continuum of smoking behavior among
children and adolescents can be described in stages of preparation,
trying, experimentation, regular smoking, and nicotine dependence or
addiction. Persons who have smoked can discontinue at any stage, but
quitting becomes more difficult as smokers progress through the
continuum and become increasingly dependent on nicotine. Nicotine
addiction is characterized by a physiologic need for nicotine,
including a tolerance for nicotine, withdrawal symptoms if an attempt
is made to quit, and a high probability of relapse after quitting.

To determine the prevalence of selected cigarette smoking initiation
and quitting behaviors among youth, the Centers for Disease Control
(CDC) analyzed data from the 1997 Youth Risk Behavior Survey (YRBS).
Findings indicate that, among US high school students in 1997, 70.2%
had tried cigarette smoking. Among students who had ever tried
cigarette smoking, 35.8% went on to smoke daily. Among those who had
ever smoked daily, 72.9% had ever tried to quit smoking and 13.5%
were former smokers.

Survey Protocols

YRBS, a component of the CDCs Youth Risk Behavior Surveillance
System, biennially measures the prevalence of priority health risk
behaviors among youth through representative national, state, and
local surveys. The 1997 national YRBS used a three-stage
cluster-sample design to obtain a representative sample of 16,262
students in grades 9 through 12 in the 50 states and the District of
Columbia. The school response rate was 79%, the student response rate
was 87%, and the overall response rate was 69%. Data were weighted to
provide national estimates, and SUDAANa was used to calculate
standard errors for determining 95% confidence intervals (CIs).

Students completed a self-administered questionnaire that included
questions about lifetime and current cigarette use, ever-daily
cigarette use, and attempts to quit smoking. Lifetime smokers were
defined as students who had ever tried smoking cigarettes, even one
or two puffs. Current smokers were defined as students who smoked
cigarettes on ³ 1 of the 30 days
preceding the survey. Ever-daily smokers were defined as students who
reported that they had "ever smoked cigarettes regularly, that
is, at least one cigarette every day for 30 days."

Quit attempts were determined from the question "Have you ever
tried to quit smoking cigarettes?" Former cigarette smokers were
defined as ever-daily smokers who were not current smokers. The
number of persons from racial/ethnic groups other than non-Hispanic
black, non-Hispanic white, and Hispanic was too small for meaningful analysis.

Results

The prevalence of lifetime smoking was 70.2% (95% CI, ± 1.9%)
overall and did not vary by sex, race/ethnicity, or grade in school (Table
1). More than one third of students (35.8%) who had tried
cigarette smoking reported ever smoking daily (Table
1). Ever-daily smoking was highest among white students (41.7%),
followed by Hispanic students (24.5%), and black students (14.9%).

Almost three fourths (72.9% [95% CI, ± 2.7%]) of ever-daily
smokers had tried to quit smoking (Table
1). Among ever-daily smokers, females (77.6%) were more likely
than males (68.7%) and white students (76.0%) were more likely than
Hispanic students (61.9%) to report ever having tried to quit. Among
ever-daily smokers, 13.5% were former smokers (Table
1).

Editorial Notes from the CDC

As with other drug addictions, nicotine dependence is a progressive,
chronic, and relapsing disorder. The optimal public health strategy
is to prevent tobacco use completely or to intervene as early in the
smoking behavior continuum as possible. Once adolescents have
established a pattern of regular use, their behavior is usually
compelled by nicotine dependence, as well as social factors. Efforts
are needed to help youth break the cycle of addiction and prevent the
disability and death associated with tobacco use.

Initiation and quitting behaviors suggest areas for intervention and
research. For example, the incidence of lifetime ever smoking among
adolescents declined in the mid-1970s and early 1980s, but increased
from 1991 to 1994, suggesting that this behavior is modifiable.
Cigarette advertising and promotion, smoking by adults and older
siblings, access to cigarettes, price of cigarettes, peer pressure,
and the degree of exposure to effective counteradvertising and
school-based prevention programs can influence patterns of initiation.

The findings in this report are consistent with previous studies
indicating that approximately 33% to 50% of persons who try smoking
cigarettes escalate to regular patterns of use. The 1990 to 1992
National Comorbidity Survey estimated that 23.6% of persons 15 to 24
years old who ever used cigarettes progressed to the final stage in
the smoking behavior continuum (ie, nicotine dependence). This
conversion rate (ie, from any use to dependence) was similar to
conversion rates for use of cocaine (24.5%) and heroin (20.1%).
Although indicators of dependence increase with the frequency of
smoking among youth, many less-than-daily smokers experience symptoms
of nicotine withdrawal when they attempt to quit.

Differences described in this report in the rate of conversion from
trying a cigarette to daily use may explain some of the racial/ethnic
differences in current smoking prevalence estimates among youth.
Black adolescents who try cigarette smoking may experience greater
social disapproval regarding their smoking behavior than white
adolescents. Among ever-daily smokers, white students were more
likely than Hispanic students and female students were more likely
than male students to have attempted to quit smoking during high
school. Investigation of the influence of early quit attempts on
long-term success is needed.

Limitations of the Findings

The findings in this report are subject to at least three
limitations. First, these data apply only to youth who attend high
school and, therefore, are not representative of all persons in this
age group. In 1996, 6% of persons 16 to 17 years old were not
enrolled in a high school program and had not completed high school.

Second, more detailed measures of cessation (ie, current interest in
quitting, recent quit attempts, and longest time abstinent from
cigarettes) could not be examined because they were not included in
the survey.

Third, a cross-sectional survey can measure only the prevalence of
various stages in the smoking behavior continuum. Transitions through
the stages of smoking behavior are best studied with a longitudinal
research design.

Cessation Programs

Most young persons who smoke regularly are already addicted to
nicotine, and the experience of addiction is similar to that among
adults. Although approximately 70% of adolescent smokers regret ever
starting, success rates have been low in the few cessation programs
designed for young persons that have reported quit rates at follow-up
(13%). Adolescents are difficult to recruit for formal cessation
programs and, when enrolled, are difficult to retain in the programs.

In September 1997, CDC conducted the first Workgroup on Youth Tobacco
Use Cessation to discuss strategies to stimulate research on
tobacco-use cessation programs. Tobacco-use cessation programs are
being evaluated in schools, health-maintenance organizations, and
state health departments, and feature adolescent team competitions,
pharmacologic agents, telephone counseling, and cooperative learning.
Evaluations of these efforts will assist in developing tobacco-use
cessation programs for youth that can be used nationwide.

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